COLLEGE PARK, Md. -- Just four of Maryland's 24 public school districts have athletic trainers working full-time with student athletes in all high schools, recent calls conducted by Capital News Service reveal.

That means thousands of student athletes throughout the state are participating in practices and games without a licensed healthcare professional on hand for emergency medical situations. The Maryland Public Secondary Schools Athletic Association estimates there are almost 114,000 student-athletes from 199 public schools participating in roughly 24 sports every year.

It's a case of the "haves and have nots," said Gina Palermo, Howard County athletic trainer and chairwoman of the Secondary Schools Athletic Trainer Committee of the Maryland Athletic Trainers Association. "You're saying that this group is okay [for public school districts to spend money on], but this group isn't," she said.

Anne Arundel, Caroline, Somerset and Worcester counties have full-time athletic trainers in all high schools for the 2013-2014 school year.

At the other end of the spectrum, Baltimore City Public Schools and the public school districts of Prince George's, Calvert, Dorchester, Allegany and Washington counties do not employ any athletic trainers in any high schools.

In between are another 14 counties in Maryland that employ part-time athletic trainers in the public high schools, or full-time trainers in some of the high schools.

Tom Hearn, the Bethesda father of a Walt Whitman High School student who sustained a concussion during the 2012 football season, is concerned.

"As the experts say, 'If you can't afford to have athletic trainers, you can't afford to have an athletic program,' " said Hearn, who has pressed Montgomery County officials to have athletic trainers in all public high schools.

Montgomery County Public Schools placed part-time athletic trainers in some of its 25 public high schools this school year. While Hearn applauds this effort, he notes those athletic trainers were donated by area medical vendors for just this academic year. Their future in the school system is uncertain.

Overall, about 61 percent of Maryland's high schools employ athletic trainers, the National Athletic Trainers Association estimates. That number is low compared to surrounding states such as Delaware (96 percent), Pennsylvania (96 percent), Virginia (87 percent) and West Virginia (85 percent).

The Have Nots

School jurisdictions without any athletic trainers cite lack of money as one of the reasons.

Prince George's County Public Schools Athletic Supervisor O'Shay Watson said the county hires emergency medical technicians for some events, but budget constraints make it difficult to hire full-time athletic trainers.

"We really do value the safety of the students, which comes first," he said. "But [you've] got to think about health benefits and things like that that come with full-time employees, and it's costly."

George C. Hall, president of the booster club at Eleanor Roosevelt High School in Greenbelt and the father of two lacrosse players for the school, said the fact that Prince George's County has no athletic trainers is upsetting.

"I'm really disappointed in that," said Hall, who is also an assistant coach for the lacrosse team. There are "very few games, if any, that we go without some kind of injury. … It's quite dangerous to not have someone out there if something happens."

Certified and licensed athletic trainers are taught to properly respond to a wide range of injuries, from sprained ankles and muscle spasms to more serious ones, such as concussions and spinal injuries.

Hall said if something does happen on the field, "it's left up to the coaching staff and the parents to assess the injury."

Some parents are sympathetic to the school systems' money woes.

Charlie Strite, father of a student athlete at Williamsport High School in Washington County, said, "obviously an athletic trainer would enhance or protect" the children more. But, he said, "it does come down to budgets."

Washington County has budgeted for seven athletic trainers next school year, one for each of its public high schools, according to school officials. Strite said it's a good move that will not only protect the kids but "also help the coach, who is probably unnecessarily burdened with making decisions that he or she's not qualified to make when it relates to an injury."

The Haves

School districts with athletic trainers in all or most of their schools cite safety as a primary concern.

"The reason we got full-time athletic trainers was to make sure our students were in athletics and doing so safely," said Bryan Ashby, supervisor of athletics in Wicomico County. "There is no way the parents would even let us go back to a contractual model. Those people [the athletic trainers] are like members of the community now."

Wicomico County has had full-time athletic trainers in three of its four high schools for at least 15 years, said supervisor of athletics Bryan Ashby. He said there is a part-time athletic trainer in one of the high schools only because that school doesn't have as many sports as the others.

Ashby said Wicomico County's athletic trainers are paid on the same scale as teachers, with annual starting salaries of about $43,000. That's right in the middle of the national average salary for full-time high school athletic trainers of $38,000 to $48,000, according to the National Athletic Training Association.

This school year is Caroline County's first year to have full-time athletic trainers in both of its public high schools, said Athletic Director Brett Ireland. They made the change for safety reasons, Ireland said, because "with the amount of sports at both schools, we need a trainer at each school."

It is Anne Arundel County's second year to have full-time athletic trainers in all of its 12 public high schools, said Greg LeGrand, the system's coordinator of athletics.

Somerset and Worcester counties have been fully staffed with athletic trainers for many years, according to school system officials.

Another nine counties - Carroll, Cecil, Charles, Frederick, Garrett, Harford, Howard, Kent and St. Mary's - have part-time athletic trainers covering most practices and games in each of their public high schools.

Queen Anne's County has one part-time athletic trainer shared between the two high schools in that county for practices and games, and another athletic trainer who only covers games.

Three counties - Baltimore, Montgomery and Talbot - have part-time athletic trainers in some public high schools.

"Part-time" is the most-used business model throughout Maryland. This typically means the athletic trainer is also either a teacher, or is contracted through a local healthcare vendor. For example, both Charles County and St. Mary's County public schools contract part-time athletic trainers through the Rehabilitation Center of Southern Maryland.

But these part-time arrangements can be strenuous. Michelle Priddy, a part-time athletic trainer covering the approximately 900 athletes of Queen Anne's County's two high schools, said sometimes it's hard keeping straight which students are at which school.

"That is mentally hard," Priddy said. "And there's times when, I do - I'm human - I forget who I saw, and three days later I'm like, 'I forgot to check on this student to see how they're doing.' "

And although nothing serious has ever happened, Priddy said sometimes athletes get injured when she's not there and "sometimes the coaches don't tell me when an athlete is injured."

"So, it can be hard communication-wise," she said.

Coaches: Not Athletic Trainers

Howard County's Palermo said the lack of athletic trainers in some schools can hinder injury reporting and ensuring return-to-play protocol is followed correctly for athletes who have been hurt. She said the Maryland Athletic Trainers Association's goal is to get athletic trainers in every high school in Maryland.

"That would be our ultimate goal, say, within 10 years," Palermo said. "But, truthfully, if they don't mandate it in the state, I don't ever see it happening."

She said it's hard to mandate something when school jurisdictions keep saying there's not enough money. But having a coach present on the field does not replace an athletic trainer - even if that coach has taken courses on care and prevention, Palermo said.

"I know that some other counties have stated that that's sufficient enough, which I think is a little ridiculous," she said. "I mean, most athletic trainers, as you know, have a master's degree … and to say that a 15-hour course is going to cover something you learn in six years is just ridiculous."

Michael Higgins, director of Towson University's Athletic Training Program, said he wouldn't want a coach performing medicine on an athlete if he or she didn't know what they were doing.

"If an athlete goes down who has a spinal cord injury and if you don't treat that spinal cord injury correctly and that athlete becomes paralyzed for the rest of their life, who's at fault?" said Higgins.

The Centers for Disease Control and Prevention in Atlanta reports that U.S. high school athletes account for 2 million injuries a year, 500,000 doctor visits and 30,000 hospitalizations.

There have been few studies done on the impact of athletic trainers at high schools. However, one study published in 2012 by the American Academy of Pediatrics looked at national sports injury data on girls' high school soccer and basketball programs. It found that high schools with athletic trainers had more diagnosed concussions, but fewer overall injuries.

Dr. Ray Kiddy, supervisor of athletics for Allegany County, said the priorities of the school's budget as a whole must be taken into account.

"I'm not saying that teachers' salaries are taking [the money]. But it really comes down to priority," he said.

Kiddy said he has tried to budget for athletic trainers for years but every time he does, his proposal has been cut. For the upcoming 2014-'15 school year, he again proposed a budget for one full-time athletic trainer for the county's three schools.

"Five or six years ago hiring an athletic trainer wasn't a priority, and now it's at the forefront," he said. "But I also know we're short $1.2 million, so I hope that's not on the chopping block."

Concerns Are Real

Greg Penczek, an athletic trainer at Towson University and president of the Maryland Athletic Trainers Association, likened an athletic trainer to an insurance policy: something rarely used but when needed, it's there for you.

Student athletes aren't "planning to get sick, they're not planning to get hurt, they're not planning to have all these things happen to them," he said. "But when they do, you want to know that something's going to be in place for them to get the adequate care they're going to need."

That care, he said, extends from the athletic field back into the classroom.

Many parents agree on their need.

George Panor's son, Greg, plays lacrosse for Queen Anne's High School, which shares a part-time athletic trainer with the other high school in the county, Kent Island. Panor said even though his son has never been injured badly enough to need attention, it's important for athletic trainers to be on the sidelines.

"Lacrosse is a rough sport," he said. "There's a lot of hitting and checking, and if something happens, there's somebody there to help them right away."

Change Moving Forward

Spokesmen for most public school districts in Maryland said they plan to maintain their athletic trainer staffing for fiscal year 2014-'15, but there will be some notable changes.

Allegany County Public Schools, which has no athletic trainers, will budget next year for one full-time trainer to share among its three high schools, said Kiddy, the supervisor of athletics. He said the superintendent sees athletic trainers as a priority, and the school system hopes to have full-time trainers in each of the high schools in the near future.

Washington County Public Schools, which also has no athletic trainers, has set a goal to have one staffed either part-time or full-time in each of its seven high schools by next year. Eric Michael, the school's supervisor of athletics, said safety is the reason for the change.

"With more and more emphasis being put on injuries and trying to train coaches to deal with them, if you hire an athletic trainer, they are trained to deal with all those things," he said. "We just feel that if we have the money to put in the budget to make sure our students are safe, that's what we're going to do."